Airway management: Overview

Abstract
Introduction: Videolaryngoscopy improves tracheal intubation outcomes compared with direct laryngoscopy in various scenarios. However, the range of videolaryngoscope designs makes it challenging to identify the most effective device. We conducted a systematic review and network meta-analysis to compare different laryngoscope designs when used for tracheal intubation of adults under general anaesthesia.

Methods: We searched six databases for randomised controlled trials of patients aged ≥16 years, requiring tracheal intubation under general anaesthesia and evaluating comparisons between the following interventions: channelled videolaryngoscopes; Macintosh blades; hyperangulated blades; video stylets; and direct laryngoscopes. The primary outcome was the incidence of failed first tracheal intubation attempts. Secondary outcomes included failed tracheal intubation; tracheal intubation difficulty; glottic view; time to tracheal intubation; and incidence of complications.

Results: We included 294 studies evaluating 44,284 patients. Channelled blades (OR (95%CrI) 0.37 (0.27-0.50), moderate certainty), Macintosh blades (OR (95%CrI) 0.45 (0.31-0.64), moderate certainty) and hyperangulated videolaryngoscopes (OR (95%CrI) 0.51 (0.39-0.68), moderate certainty) reduced the incidence of failed first tracheal intubation significantly compared with direct laryngoscopes, with channelled-blade devices ranking highest for this outcome. No significant difference was observed between video stylets and direct laryngoscopes for this outcome (OR (95%CrI) 0.67 (0.16-3.00), low certainty). All three videolaryngoscope designs also reduced failure rates across second and third tracheal intubation attempts; decreased the likelihood of difficult tracheal intubation; improved glottic view; and lowered the incidence of oesophageal intubation and airway tissue damage. Channelled- and hyperangulated-blade videolaryngoscopes significantly improved glottic view compared with Macintosh-blade designs.

Discussion: We are moderately certain that the three designs of videolaryngoscopes enhance tracheal intubation effectiveness, safety and postoperative recovery compared with direct laryngoscopes. Channelled videolaryngoscopes and hyperangulated blades might provide superior glottic views compared with Macintosh-blade videolaryngoscopes. No definitive conclusions can be drawn regarding the comparative tracheal intubation performance across different video-assisted devices and designs.

Abstract
Tracheal extubation is an integral part of airway management. Even though available data indicated that the incidence of complications immediately after tracheal extubation may be higher than during tracheal intubation, it is significantly underexplored in the scientific literature in comparison with tracheal intubation. Failure to re-secure the airway during or immediately after tracheal extubation may have fatal consequences. Closed claims analyses have highlighted the seriousness of adverse events occurring postextubation. Consequently, a well-planned strategy for tracheal extubation is as important as for the intubation and is correctly regarded as a logical extension of an intubation strategy. This narrative review focusses on the challenges of tracheal extubation and complications of routine and 'at-risk' extubation in adults. It provides the reader with a risk stratification before extubation. Guidelines for tracheal extubation including advanced techniques for tracheal extubation of patients 'at-risk' are followed by a detailed step-by-step approach for video-assisted tracheal tube exchange in patients with a difficult airway.

Abstract
Anaesthetic airway incidents persist as a significant concern in patient safety and, despite extensive investigations, continue to cause patient harm. Traditional safety investigations predominantly adhere to Safety-I principles, focusing on identifying and rectifying errors, often yielding limited new findings. In this analysis conducted within the webAIRS database, the focus shifted towards Safety-II principles. The aim of this study was to identify factors contributing to airway management safety by examining incidents that did not result in adverse patient outcomes. Incidents categorised as 'difficult intubation' or 'failed intubation' without causing harm to the patient and reported to webAIRS between 2016 and 2022, were included in the analysis.An inductive qualitative content analysis of narrative data from 129 such incidents revealed that the majority of reported events depicted scenarios deviating from controlled and planned circumstances. During the analysis four themes were identified: patient factors, system factors, individual anaesthetist factors and airway management strategy. Within the first three themes, multiple factors were linked to airway management strategies. The findings of this qualitative analysis show that 'Work as done' often differs from 'Work as imagined'.This qualitative analysis highlighted the dynamic nature of human management, as individuals respond to unplanned or unexpected events, showcasing adaptability and positive contributions to incident performance. Expanding the understanding of patient safety to also include Safety-II principles, provides a deeper and wider understanding of airway management safety.

Abstract
Before completion of this study, there was insufficient evidence demonstrating the superiority of videolaryngoscopy compared with direct laryngoscopy for elective tracheal intubation. We hypothesised that using videolaryngoscopy for routine tracheal intubation would result in higher first-pass tracheal intubation success compared with direct laryngoscopy. In this multicentre randomised trial, 2092 adult patients without predicted difficult airway requiring tracheal intubation for elective surgery were allocated randomly to either videolaryngoscopy with a Macintosh blade (McGrath™) or direct laryngoscopy. First-pass tracheal intubation success was higher with the McGrath (987/1053, 94%), compared with direct laryngoscopy (848/1039, 82%); absolute risk reduction (95%CI) was 12.1% (10.9-13.6%). This resulted in a relative risk (95%CI) of unsuccessful tracheal intubation at first attempt of 0.34 (0.26-0.45; p < 0.001) for McGrath compared with direct laryngoscopy. Cormack and Lehane grade ≥ 3 was observed more frequently with direct laryngoscopy (84/1039, 8%) compared with McGrath (8/1053, 0.7%; p < 0.001) No significant difference in tracheal intubation-associated adverse events was observed between groups. This study demonstrates that using McGrath videolaryngoscopy compared with direct laryngoscopy improves first-pass tracheal intubation success in patients having elective surgery. Practitioners may consider using this device as first choice for tracheal intubation.